Multiple Sclerosis

Multiple sclerosis (MS) is a chronic, potentially debilitating disease that affects your central nervous system,which is made up of your brain and spinal cord. Multiple sclerosis is widely believed to be an autoimmunedisease, a condition in which your immune system attacks components of your body as if they're foreign.In multiple sclerosis, the body mistakenly directs antibodies and white blood cells against proteins in the myelinsheath, a fatty substance that insulates nerve fibers in your brain and spinal cord. This results in inflammationand injury to the sheath and ultimately to the nerves that it surrounds. The result may be multiple areas of scarring (sclerosis). Eventually, this damage can slow or block the nerve signals that control musclecoordination, strength, sensation and vision.Multiple sclerosis affects an estimated 300,000 people in the United States and probably more than 1 millionpeople around the world — including twice as many women as men. Most people experience their first signs or symptoms between ages 20 and 40.Multiple sclerosis is unpredictable and varies in severity. In some people, multiple sclerosis is a mild illness, butit can lead to permanent disability in others. Treatments can modify the course of the disease and relievesymptoms.

Signs and symptoms

Signs and symptoms of multiple sclerosis vary widely, depending on the location of affected nerve fibers.Multiple sclerosis symptoms may include:

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Numbness or weakness in one or more limbs, which typically occurs on one side of your body at a timeor the bottom half of your body

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Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement

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Double vision or blurring of vision

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Tingling or pain in parts of your body

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Electric-shock sensations that occur with certain head movements

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Tremor, lack of coordination or unsteady gait

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Fatigue

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DizzinessIn some cases, people with multiple sclerosis may also develop muscle stiffness or spasticity, slurred speech,paralysis, or problems with bladder, bowel or sexual function. Mental changes, such as forgetfulness or difficulties with concentration, also may occur.

Causes

Your central nervous system contains millions of nerve cells that send their electrical signals to and from your brain along wire-like extensions of the cells called axons, or nerve fibers. Myelin is the fatty substance thatcoats and protects these fibers, similar to the way insulation shields electrical wires.

In people with multiple sclerosis, the immune system mistakenly destroys the cells that produce the myelinsheath. As a result, myelin becomes inflamed and swollen and detaches from the nerve fibers. The detachedmyelin may eventually be destroyed. Firm or hardened (sclerosed) patches of scar tissue form over the fibers.When nerve impulses reach a damaged area, some impulses are blocked or delayed from traveling to or from

your brain. Ultimately, this process leads to degeneration of the nerves themselves, which likely accounts for the permanent disabilities that may develop in MS.Doctors and researchers don't understand what causes this autoimmune reaction. Something seems to trigger the condition in susceptible people.Genetic factors may make certain people more susceptible to multiple sclerosis. But genetic susceptibility isonly part of the explanation. A number of researchers believe the disorder is related to a protein that mimicsthe myelin protein, which may be introduced into the body by a virus. Other researchers believe that theimmune system overreacts toward myelin proteins in people with MS, which leads to an abnormal tendency todevelop autoimmune disease.A period of disease activity (exacerbation) may be triggered by a viral infection, such as a cold or flu, or bychanges in the immune system during the first six months following a pregnancy.

Patterns of MS

Whatever the multiple sclerosis cause or trigger, the disease occurs in four main patterns:

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Relapsing remitting.

This type of multiple sclerosis is characterized by clearly defined flare-ups,followed by periods of remission. The flare-ups typically appear suddenly, last a few weeks or months,and then gradually disappear. Most people with MS have this form at the time of diagnosis.

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Primary progressive.

People with this less common form of multiple sclerosis experience a gradualdecline, without periods of remission. People with this form of MS are usually older than 40 when signsor symptoms begin.

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Secondary progressive.

More than half the people with relapsing remitting MS eventually enter astage of continuous deterioration referred to as secondary progressive MS. Sudden relapses mayoccur, superimposed upon the continuous deterioration that characterizes this type of multiplesclerosis.

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Progressive relapsing.

This is primary progressive MS with the addition of sudden episodes of newsymptoms or worsened existing ones. This form is relatively uncommon.

Treatment

If your attacks are mild or infrequent, your doctor may advise a wait-and-see approach, with counseling andobservation.

Medications for relapsing MS

If you have a relapsing form of the disease, your doctor may recommend treatment with disease-modifyingmedications early in the course of disease. You can't take these medications if you're pregnant or may becomepregnant. These medications for multiple sclerosis treatment include:

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Beta interferons.

Interferon beta-1b (Betaseron) and interferon beta-1a (Avonex, Rebif) are geneticallyengineered copies of proteins that occur naturally in your body. They help fight viral infection andregulate your immune system.If you use Betaseron, you inject yourself under your skin (subcutaneously) every other day. If you useRebif, you inject yourself subcutaneously three times a week. You self-inject Avonex into your muscle(intramuscularly) once a week. These medications reduce but don't eliminate flare-ups of multiplesclerosis. It's uncertain which of their many actions lead to a reduction in disease activity and what their

long-term benefits are. Beta interferons aren't used in combination with one another; only one of thesemedications is used at a time.The Food and Drug Administration (FDA) has approved beta interferons only for people with relapsingforms of MS who can still walk. Beta interferons don't reverse damage and haven't been proved tosignificantly alter long-term development of permanent disability. Some people develop antibodies tobeta interferons, which may make them less effective. Other people can't tolerate the side effects,which may include symptoms similar to those of the flu (influenza).Doctors generally recommend beta interferons for people who have more than one attack of MS a year and for those who don't recover well from flare-ups. The treatment may also be used for people whohave a significant buildup of new lesions as seen on an MRI scan, even when there may not be major new symptoms of disease activity.The FDA has approved the use of several beta interferons for people who've experienced a singleattack that suggests multiple sclerosis, and who may be at risk of future attacks and developing definiteMS. Risk of MS may also be suggested when an MRI scan of the brain shows lesions that predict ahigh risk of conversion to definite MS. Controversy exists as to whether these people should take theseexpensive and often inconvenient drugs for indefinite periods, especially because some people do wellboth in the short term and long term without therapy. Some doctors prefer to observe people at highrisk with follow-up examinations and MRI scans to document any ongoing inflammatory disease activitybefore recommending long-term therapies such as beta interferon.

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Glatiramer (Copaxone).

This medication is an alternative to beta interferons if you have relapsingremitting MS. Doctors believe that glatiramer works by blocking your immune system's attack onmyelin. You must inject glatiramer subcutaneously once daily. Side effects may include flushing andshortness of breath after injection.

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Natalizumab (Tysabri).

This drug is administered intravenously once a month. It works by blocking theattachment of immune cells to brain blood vessels — a necessary step for immune cells to cross intothe brain — thus reducing the immune cells' inflammatory action on brain nerve cells.During clinical trials, this drug was shown to significantly reduce the frequency of attacks in people withrelapsing MS. After receiving FDA approval, however, the drug was withdrawn from the marketbecause of reports from three people who developed a rare, often fatal, brain disorder calledprogressive multifocal leukoencephalopathy.In 2006, after reconsideration of the drug's benefits for people with multiple sclerosis, the FDA agreedto allow the drug to be marketed again under specific conditions. Chief among these conditions is therequirement that doctors, pharmacists and patients be involved in a special distribution program knownas TOUCH in order to prescribe, dispense or receive the drug. Because of the drug's risks, it'sgenerally recommended only for people whose condition hasn't responded to other forms of MStherapy. Furthermore, there has been no study direct comparing natalizumab to existing treatments toprove whether it's superior to existing treatments.

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Other medications.

Mitoxantrone (Novantrone) is a chemotherapy drug used for many cancers. Thisdrug is also FDA-approved for treatment of aggressive forms of relapsing remitting MS, as well ascertain forms of progressive MS. It's given intravenously, typically every three months.Mitoxantrone may cause serious side effects, such as heart damage, after long-term use, so it'stypically not used for longer than two to three years. And it's typically reserved for people with severe